Clinical Notes : Dermatology

192. Bee and Wasp stings

What insects sting and how ?

 

Insects that sting are members of the hymenoptera class of insects:

  • Vespids: yellow jacket, hornet and wasp

  • Apids: bumblebee and honeybee.

 

The stinging apparatus is located in the abdomen of the female insect and consists of a sac containing venom and a barbed stinger.

 

When a bee stings, the apparatus becomes detached from the insect leading to its death, hence bees can only sting once. However wasps can sting multiple times and do not leave their sting behind in the skin.

 

 

Symptoms of a bee or wasp sting

A sting from a wasp causes a sharp pain that usually lasts for a few seconds.

The area that has been stung often become red, painful and swollen. It may cause local irritation, itching or pain for hours to days afterwards.

 

A sting from a bee feels similar to that from a wasp however it leaves a sack, filled with venom in the skin.

 

 

The range of reactions to stings

 

Most people suffer only minor symptoms after a sting. However some people suffer more severe or even life-threatening reactions.

 

 

Minor localised reaction

  • The site of the sting becomes red and slightly painful or itchy for a few days.

  • Sometimes, blisters may occur.

 
 
 
 

Localised reactions to bee and wasp stings

Bee sting

Bee sting reaction

Wasp sting reaction

 

Large localised reaction

  • The affected area may swell and become painful

  • The swelling may last between 48 hours and seven days, and can often be confused with cellulitis (1)

  • Similar reactions occur with subsequent stings, with the risk of anaphylaxis being less than 5% per episode.(2)

Large localised reactions to bee stings

Bee sting

Honey bee

Honey bee

 

Systemic reaction

Life-threatening allergic reactions due to anaphylaxis are rare.

They are more likely in people that have been stung before, because of sensitisation to the insect venom.

  • Symptoms usually start within 10-20 minutes of being stung, but may occur up to 72 hours later.

  • The clinical features are the same as anaphylaxis due to other causes, and include urticaria, flushing, angioedema, life threatening circulatory collapse and bronchospasm. It may be fatal.

  • The incidence of anaphylaxis to bee stings in the general population is estimated to be 0.3-3%.(1)

  • Toxic reactions leading to anaphylaxis can occur in people who have suffered multiple simultaneous stings (between 50-100), as the large amount of venom stimulates IgE production.

Multiple wasp stings

 

What should you do if a bee or wasp stings you?

A bee's sting should be removed immediately from the skin.

As a wasp does not leave its sting behind you cannot remove it.

Avoid squeezing more venom from the sack of a bee sting into the skin when trying to remove it with fingers or tweezers.

It is best scraped off with a flat card.

The severity of the reaction will determine if any medical treatment is needed.

  • Wash the local area with water and keep it clean.

  • Try not to scratch or rub the area.

  • Use a cold compress over the area to help to reduce swelling.

  • Simple analgesia is usually adequate, for example paracetamol or ibuprofen.

  • Oral antihistamine tablets reduce itch and swelling

  • Topical ‘bite or sting’ creams can give some symptomatic relief. They usually contain local anaesthetic, antihistamine or corticosteroid.

A large localised reaction with severe swelling may warrant a course of oral steroids, for example prednis(ol)one for 3-5 days.

 

Life threatening reaction or anaphylaxis is a medical emergency.

  • Adrenaline (e.g. EpiPen®) should be administered if available for anyone with signs of shock, breathing difficulty or airway swelling.

  • In hospital, Advanced Life Support (ALS) protocols should be followed.

  • Those who are at risk of anaphylaxis should be supplied with an EpiPen and counselled, along with their close relatives, responsible adults or care workers, about how and when to use it.

 

Unusual reactions to bee and wasp stings

Bee and wasp sting reactions are sometimes very persistent, lasting weeks or months.

There have been case reports of vasculitis, serum sickness, neuritis and encephalitis occurring in the days to weeks following insect stings.(3) 

There are even reports of secondary parkinsonianism following hymenoptera stings (4) and cerebral infarction.(5) Some of these have occurred after anaphylactic reactions to stings.

 

Unusual reactions to bee and wasp stings

Persistent wasp sting reaction

Purpuric wasp sting reaction

 

Infected bee and wasp stings

Cellulitis and lymphangitis can occur if bacteria enter the break in the skin at the site of the sting.

Infection should be treated with antibiotics.

Skin and serum allergy testing

Skin prick tests and serological reactivity testing can be performed to identify those who may suffer more severe reactions from insect stings.

This is useful to identify where venom immunotherapy (VIT) would be of benefit.

Immunotherapy for insect stings

Venom immunotherapy (VIT) is an effective treatment to protect venom allergic people from sting-induced anaphylaxis (6).

It is not generally indicated for adults with systemic reactions limited to the skin (eg, urticaria, angioedema or erythema).(7)

Venom immunotherapy is usually performed by an immunology or allergy specialist. It involves a course of injections containing a very small amount of the allergen, which in this case is insect venom.

The injections are given under the skin repeatedly over a prolonged period of time, often several years.

The amount of venom injected is slowly increased throughout the course.

Eventually desensitization occurs, meaning the body becomes less sensitive to the venom.

 
 

Swelling due to bee venom immunotherapy

Preventing insect stings

Simple measures can be taken to reduce the risk of being stung by these insects:

  • Keep your skin covered with long sleeves, trousers and shoes.

  • If a stinging insect is flying around you, try to move away slowly without waving your arms around.

  • Apply insect repellent to exposed skin; DEET is thought to be the most effective.

  • Avoid areas that attract wasps, bees and hornets, including flowering plants, rubbish, fruit trees, wasp or bee nests.

  • Keep food and drink covered when outside

  • Avoid wearing bright clothes, particularly yellow, when stinging insects are likely to be around.

  • Try not to bother wasps and bees. If a wasp nest is near your house, have a pest control expert visit to get rid of it.

 
 
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Bee and wasp stings

DermNetNZ  (CCPL)

Access

1. Reisman RE.

Insect stings.

The New England Journal of Medicine 1994:331(8);523-527.

Access

2. Mauriello PM, Barde SH, Georgitis JW, Reisman RE.

Natural history of large local reactions from stinging insects.

J Allergy Clin Immunol 1984:74;494-498.

Access

3. Light WC, Reisman RE, Shimizu M, Arbesman CE.

Unusual reactions following insect stings:clinical features and immunologic analysis.

J Allergy Clin Immunol 1977;59:391-397.

Access

4. Mittal, Ruchika; Munjal, Sanjay; Khurana, Dheeraj; Gupta, Ashok

Parkinsonism following Bee Sting: A Case Report.

Case Reports in Neurological Medicine (2012).

Access

5. J. E. Riggs, L. M. Ketonen, J. P. Wymer, R. L. Barbano, L. K. Valanne, J. B. Bodensteiner

Acute and delayed cerebral infarction after wasp sting anaphylaxis.

Clinical Neuropharmacology 1994;17(4):384-388, 1994.

Access

6. Boyle RJ, Elremeli M, Hockenhull J, Cherry MG, Bulsara MK, Daniels M, Oude Elberink JN

Venom immunotherapy for preventing allergic reactions to insect stings.

Cochrane Database Syst Rev 2012;10:008838.

Access

7. Golden DB, Demain J, Freeman T, et al.

Stinging insect hypersensitivity: A practice parameter update 2016.

Ann Allergy Asthma Immunol 2017; 118:28.

Access

There are 13 species of true bumblebee in Ireland.

Bumblebees are identified by the colour patterns on their body (thorax) and ‘tail’ (abdomen).

There are 6 species of cuckoo bumblebee in Ireland.

They are called cuckoo bumblebees because they steal the nest of a true bumblebee instead of making their own.

The most common bumblebees in Ireland are the white tailed bumblebee and the common carder bumblebee.

White tailed bumblebee

Common carder bumblebee

Field Cuckoo bumblebee

The honeybee is the type of bee that most people are familiar with.

It is very difficult to assess the conservation status of Ireland’s native honeybee because beekeepers import bees from outside Ireland and these have mixed with the native species

Honey bee

Honey bee

Honey bee

Although most people don’t know they even exist, solitary bees make up most of the bee species in Ireland.

here are 19 species of bumblebee, one species of honeybee and 81 species of other bee, most of which are solitary and 22 of which are cuckoo bees, kleptoparasites of solitary bees.

Solitary bees take one whole year to pass though a complete life cycle, and may only survive as adults for 2 weeks. This isn’t long enough for them to raise their offspring, so the young bees have to fend for themselves, hence the term ‘solitary bee’.

 

Common in Irelend are mining bees, leafcutter bees and mason bees.

  • Mining bees are the bees that leave little piles of earth on your lawn – these miniature volcanoes are the work of mining bees that nest in the ground. There are many different species, such as the ashy mining bee, and they range from dark fluffy orange to a pale fluffy yellow. Mining bees live in all environments ranging from quarries to gardens often taking advantage of beetle tunnels.

  • Leafcutter bees are responsible for removing semi-circular sections of plant foliage. There are seven different types in the Ireland. They use cut leaves to build a nesting cell for a single larvae. They nest in beetle holes and need around 40 pieces of leaf to make their nursery.

  • Mason bees live in the brickwork of houses, wood, hard dead flower stalks, and walls. They have quite black faces, with a deep ginger body, and a squarer head than other bees. They collect building material such as mud to construct a small home in masonry study gaps.

Mining bee

Leaf-cutter bee

Mason bee

QUE.jpg

The state of Ireland's bees

Environment and Heritage service

Online February 2020

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Wasps in Ireland

Bespoke Info.

Online February 2020

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